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Accreditation Council for Graduate Medical Education
Competency-based
Medical Education (CBME)
and Transformation
Future Directions of Credentialing Research in
Nursing: A Workshop
© 2014 Accreditation Council for Graduate Medical Education
Disclosures
 Eric Holmboe
 Employed by ACGME
 Formerly employed by ABIM
 Receives royalties for textbook from
Mosby-Elsevier
© 2014 Accreditation Council for Graduate Medical Education
Why CBME: System Needs
Frenk J. Health professionals for a new century: transforming education
to strengthen health systems in an interdependent world. Lancet. 2010
© 2014 Accreditation Council for Graduate Medical Education
3
What Are The Outcomes?
• A competent (at a minimum) practitioner
aligned with:
CMS Triple Aim
© 2014 Accreditation Council for Graduate Medical Education
The Assessment “System”
Unit of Analysis:
Program
Residents
FB
Assessments within
Program:
• Direct observations Qual/Quant
• Audit and
“Data”
D
performance data
Synthesis:
• Multi-source FB
Committee
• Simulation
• ITExam
Faculty, PDs
and others
J
U
D
G
E
M
E
N
T
FB
Milestones and EPAs
as Guiding Framework and Blueprint
© 2014 Accreditation Council for Graduate Medical Education
Accreditation
D
FB
Certification and
Credentialing
Unit of Analysis:
Individual
P
U
B
L
I
C
© 2014 Accreditation Council for Graduate Medical Education
Milestones
• By definition a milestone is a
significant point in development.
• Milestones should enable
residents, fellows and the
training program to better
determine an individual’s
trajectory of competency
acquisition.
Competency
Sub-competency
Developmental
Progression or Set of
Milestones
PC1. History (Appropriate for age and impairment)
Level 1
Acquires a
general medical
history
Level 2
Acquires a basic
physiatric history
including
medical,
functional, and
psychosocial
elements
Level 3
Acquires a
comprehensive
physiatric history
integrating medical,
functional, and
psychosocial
elements
Level 4
Efficiently acquires
and presents a
relevant history in a
prioritized and
hypothesis driven
fashion across a
wide spectrum of
ages and
impairments
Seeks and obtains
data from secondary
sources when needed Elicits subtleties and
information that may
not be readily
volunteered by the
patient
Specific
Milestone
© 2014 Accreditation Council for Graduate Medical Education
Level 5
Gathers and
synthesizes
information in a
highly efficient
manner
Rapidly focuses on
presenting problem,
and elicits key
information in a
prioritized fashion
Models the
gathering of subtle
and difficult
information from the
patient
Entrustable Professional Activities
• EPAs represent the routine professional-life
activities of physicians based on their specialty
and subspecialty
• The concept of “entrustable” means:
• ‘‘a practitioner has demonstrated the necessary
knowledge, skills and attitudes to be trusted to
perform this activity [unsupervised].’’1
1Ten
Cate O, Scheele F. Competency-based postgraduate
training: can we bridge the gap between theory and
clinical practice? Acad Med. 2007; 82(6):542–547.
Competencies, Milestones and EPAs
COMPETENCY
COMPETENCY
COMPETENCY
COMPETENCY
MILESTONES
MILESTONES
MILESTONES
MILESTONES
Entrustable Professional Activity
Characteristic
Competencies
Milestones
EPAs
Granularity
Low
Moderate to High
Low to Moderate
Synthetic/Integrated Moderate
Low to Moderate
High
Practicality
(application)
Low
Moderate
High
Conceptual
High
Low
Low to Moderate
© 2014 Accreditation Council for Graduate Medical Education
Milestones and EPAs as Roadmap
Observations:
1) Journey not a
straight line
2) More than one
path (but not
infinite)
3) “If you don’t know
where you are
going, any road
will get you there”
© 2014 Accreditation Council for Graduate Medical Education
Dreyfus & Dreyfus Development Model
Expert/
Master
Proficient
Competent
Advanced Beginner
Novice
Time, Practice, Experience
Dreyfus SE and Dreyfus HL. 1980
Carraccio CL et al. Acad Med 2008;83:761-7
© 2014 Accreditation Council for Graduate Medical Education
Dreyfus & Dreyfus Development Model
MILESTONES
Curriculum
Curriculum
Curriculum
Curriculum
Curriculum
Assessment
Assessment
Assessment
Assessment
Assessment
Expert/
Master
Proficient
Competent
Advanced Beginner
Novice
Time, Practice, Experience
Dreyfus SE and Dreyfus HL. 1980
Carraccio CL et al. Acad Med 2008;83:761-7
© 2014 Accreditation Council for Graduate Medical Education
Effective Assessment System Processes
 Most important component of curriculum is the
clinical care clnicians provide and experience
 Clarity on right outcomes linked to curriculum
 Integration of the educational and clinical systems
 Right combination and synthesis of assessment
methods
 Critical importance of shared understanding &
mental models of competence
 Competencies, milestones, entrustable professional
activities (EPAs)
Improvements We Can Implement Now
 Observe, observe, observe
 There is currently no substitute for ongoing
observation and feedback from an expert clinician.
 Stop seeking the grail of assessment forms.
 Assessment forms are only as good as the
individual using them.
 Align assessment forms with purpose & construct.
 Invest in assessor development.
 Refine use of work-based assessment methods.
 Treat local assessment practices as a continuous
quality improvement activity.
© 2014 Accreditation Council for Graduate Medical Education
Next Steps for Assessment
 Need to advance development of workbased assessment (WBA) methods




Interprofessional team care
Effective use of clinical decision support
Quality, systems-based practice, safety
Sophisticated communication skills
 Embed WBA into routine clinical work
 EMRs will need to evolve
 Robust and longitudinal feedback loops
© 2014 Accreditation Council for Graduate Medical Education